Basic Information
| Provider Information | |||||||||
| NPI: | 1205507571 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GURTISEN | ||||||||
| FirstName: | LILLIE | ||||||||
| MiddleName: | |||||||||
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| Credential: | RN BSN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 361 ADAMS AVE | ||||||||
| Address2: | |||||||||
| City: | GLENCOE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600221814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7088215438 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 18601 N CREEK DR | ||||||||
| Address2: | |||||||||
| City: | TINLEY PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604776397 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7083428100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2021 | ||||||||
| LastUpdateDate: | 09/25/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 041223892 | IL | N | Nursing Service Providers | Registered Nurse | 163W00000X | 223892 | IL | Y | Nursing Service Providers | Registered Nurse |
No ID Information.